NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
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1 NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have EVER had any of these conditions, please indicate with an X or a ) Thank you for answering all of the following questions. Your health is important to us. Breast Conditions Recent Mammogram When? History of Abnormal Mammogram Breast Cancer Breast Implants Fibrocystic Breast Gyn Conditions Abnormal Pap Smear Endometriosis Fibroids Herpes (circle which type- oral and/or genital) HPV (Human Papilloma Virus) Menopause Ovarian Cysts or PCOS (polycystic ovary) Severe PMS Heart or Circulation Conditions (Cardiovascular) Blood Clot (DVT or Pulmonary Embolism) Fainting (Syncope) High Blood Pressure Varicose Veins Endocrine (Glandular) Disorders Diabetes (circle which type: Type 1 or Type 2) Pituitary Gland Disease Thyroid Disease Immune System Diseases Lupus or Rheumatoid Arthritis Gastrointestinal (GI) Problems Blood in Stool Crohn s Disease or Ulcerative Colitis Hemorrhoids Hepatitis Irritable Bowel Syndrome Had Colonoscopy? When? Blood (Hematologic) Disorders Anemia Clotting Disorder Sickle Cell Trait or Disease Thalassemia Musculoskeletal Disorders Fractures or Broken Bones Arthritis or Joint Pain Severe Back Pain or Back Disease Neurologic Disorders Migraines or Severe Headaches Seizure Disorder (Epilepsy) TIA or Stroke Mental Health Conditions Bipolar (Manic-Depressive) Nervous Breakdown OCD (Obsessive-Compulsive) Severe Anxiety or Panic Attacks Severe Depression or h/o Postpartum Depr. Gyn Hist 1
2 Respiratory (Lung) or ENT Disorders Allergies, Hay Fever Asthma Bronchitis/Pneumonia Lung Cancer Sinusitis or Sinus Problems Sleep Apnea Urinary (Urological) Disorders Frequent Bladder Infections Kidney Stones or Other Problems Skin Conditions Acne (severe) Eczema Excess Hair Growth Hives Psoriasis What is your height? What is your recent weight? REVIEW OF SYSTEMS RECENT ABNORMAL SYMPTOMS (Are you currently experiencing any of the following symptoms to a significant degree?) (If so, please indicate with an X or a ) General Fatigue or Weakness Fever, Chills or Sweats Loss of Appetite Unexplained weight gain or loss Eyes, Ears, Nose and Throat Dizziness Nose Bleeds Sore Throat Vision or Hearing Changes Breasts Breast Lump or Lumps Breast Pain or Tenderness Nipple Discharge (other than white) Cardiovascular Chest Pain or Tightness Irregular Heartbeat or Palpitations Respiratory Chronic Coughing Shortness of Breath Wheezing Gastrointestinal Diarrhea (watery stool) Heartburn Nausea or Vomiting Severe Constipation Urinary Burning with Urination Frequent Urination Urgency of Urination Leakage of Urine Waking at night 2 or more times to urinate Gyn Bleeding After Intercourse Bleeding Between Periods Bumps or Sores in Genital Area Cycles Longer than 35 days? Heavy Flow more than 3 days? Pain Before or During Periods Pain with Ovulation Pain during intercourse Periods last 8 or more days Severe Pain or Cramps with Periods Severe PMS Symptoms Vaginal Discharge Vaginal Itching, Burning or Dryness Skin Itching Moles or Sores Rash Neurologic Dizziness Headaches Memory Problems Musculoskeletal Joint Pain (Back, Knee, Wrist, Hip) Joint Swelling Muscle Cramping or Pain Endocrine (Glandular) Excessive Hair Growth Excessive Hair Loss Intolerance to Heat or Cold Low Sex Drive Psychiatric Excessive Anxiety, Worries, Stress Severely Depressed Feeling Out of Control Patient Name Gyn Hist 2
3 PAST SURGERY or HOSPITAL ADMISSIONS List all Surgeries or Hospital Admissions - EVER Year CURRENT PRESCRIPTION MEDICATIONS YOU ARE TAKING Medication name, dosage (amount) and reason (include meds as needed ) Recent Vaccines (Please enter here): PHARMACY INFO (so we can E-prescribe for you) Pharmacy Name: Phone # Pharmacy Address: Fax # Do we have permission to import your medication history using our electronic prescription software? YES NO VITAMINS, HERBS AND SUPPLEMENTS YOU ARE TAKING Product name and how often (include dosage if known) ALLERGIES (circle choices) If yes, please list all allergies and your allergic reaction Do you have ANY allergies? NO ALLERGIES Allergic to Latex? YES NO Allergic to Reaction Patient Name Gyn Hist 3
4 FAMILY MEDICAL HISTORY FOR THE ITEMS BELOW, PLEASE CONSIDER the following relatives: (Yourself, Mother, Father, Sister, Brother, Sons, Daughters, Half-Siblings, Aunts, Uncles, Grandparents, Nieces, and Nephews). This is a screening method to see if you are at increased risk for having a genetic mutation that can cause hereditary cancer. CANCER RISK ASSESSMENT Y N Have YOU or a Family Member ever been diagnosed with Breast Cancer? Y N Have YOU or a Family Member ever been diagnosed with Colon Cancer or Endometrial Cancer? Y N Have YOU or a Family Member had ten or more lifetime colon polyps (colorectal adenomas)? Y N Are YOU of Jewish ancestry with Breast Cancer in any Family Member? Y N Have YOU or ANY FAMILY MEMBER been diagnosed with Ovarian Cancer at any age? Y N Do you have 3 or more Family Members with any of the below cancers on the same side of the family diagnosed at any age? Cancers: Breast, Colon, Endometrial (Uterine) Y N Are there any Men in your family that have been diagnosed with Breast Cancer? Please Answer Yes or No, indicate age, and who has that specific condition. OTHER CONDITIONS 1. DIABETES, HIGH CHOLESTEROL, THYROID DISEASE 2. HIGH BLOOD PRESSURE, HEART ATTACK, BLOOD CLOTS, STROKE Please CIRCLE CONDITION (on the left) and indicate below who has that specific condition. 3. ASTHMA or OTHER LUNG DISEASE 4. KIDNEY DISEASE or KIDNEY STONES 5. GYN DISEASES, OVARIAN, CERVICAL OR UTERINE CANCER, UTERINE FIBROIDS 6. MUSCULOSKELETAL DISEASES, OSTEOPOROSIS OR OSTEOPENIA 7. NEUROLOGIC or NERVOUS SYSTEM DISEASE, MIGRAINES 8. SEVERE DEPRESSION or OTHER MENTAL HEALTH CONDITION 9. GENETIC DISEASE or BIRTH DEFECTS of ANY KIND 10. LEUKEMIA, LYMPHOMA or ANY BLOOD or BONE MARROW DISEASE 11. ANY RELATIVE EVER HAD A BONE MARROW TRANSPLANT Comments: Patient Name Gyn Hist 4
5 SOCIAL HISTORY Do you get 3 servings daily of dairy products (milk, yogurt, cheese, cottage cheese)? Type of Exercise: How Often? Alcohol Intake: NONE or Smoking History: NONE or Drug Use: NONE or Hazardous Exposures: NONE or Your Occupation: MENSTRUAL HISTORY AGE of FIRST MENSTRUAL PERIOD *CYCLE LENGTH (28 days or?) # of DAYS of BLEEDING during a *PERIOD # days heavy # days light/spotting DATE of LAST NORMAL MENSTRUAL PERIOD (if abnormal, describe) BIRTH CONTROL METHOD If none, please enter reason LAST Pap Smear (MM/YY) By who? (*period means # of bleeding days; cycle length means total # of bleeding & non-bleeding days until the next period begins) PREGNANCY SUMMARY (how many?) Total Number of Pregnancies Full Term Births (> 37 wks) Premature Births (< 37 wks) Terminations Miscarriages Ectopic pregnancies Number of Living Children Comments: PREGNANCY DETAILS Child s Birthdate # weeks at Delivery Length of Labor Birth Wt. M or F Type of Delivery (Vaginal or C/S) Anesthesia Complications/ Problems Location Form Revised November 2016 Patient Name Gyn Hist 5
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
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